Was There Incentive At VA For Behavior That Created Scandal?

It's ALL THINGS CONSIDERED from NPR West. I'm Arun Rath. It's time to fix the Department of Veterans Affairs. That's the consensus in Washington, where a bipartisan bill to do just that is expected to hit the floor this week. At least 18 veterans died while waiting for doctors appointments at a VA hospital in Arizona. While we still don't know if they died because of the wait, acting VA Secretary, Sloan Gibson, says the VA has failed America's veterans.

SLOAN GIBSON: They have had to wait too long for the care that they deserve. And in too many instances, we have behaved in ways that are not consistent with our values.

RATH: It sounds strange, but Gibson is going to eliminate the VA goal that veterans see a doctor within 14 days of making an appointment.

KENNETH KAISER: There's no question now, and I think acting Secretary Gibson was clear that setting the performance standard 14 days was simply unrealistic.

RATH: That's Doctor Kenneth Kaiser. He was an undersecretary for health in the Department of Veterans Affairs in 1990s. He says, that goal may have incentivized behavior that led to the VA scandal.

KAISER: There was a lot of pressure from leadership to meet that standard. There were financial bonuses tied to meeting it. I think the combination of real-world shortages of doctors, and in some cases, not having the modern facilities to provide care, the overly complicated scheduling system -when you put that within the context of an unrealistic performance goal, you know, it's a toxic prescription. And I think that some of what we're seeing is a result of that.

RATH: You've written about how the two major narratives out there - about how the source of the problems at the VA. You have, on the one side, people blaming government incompetence. On the other, there are people who blame a lack of funding. How would you explain it?

KAISER: Neither of those narratives actually capture the complexity and all of the dimensions of the problem. Some of these problems are quite technical - What needs to be done to fix the performance management system, what needs to be done to fix the information technology system. But there's no question that the VA, because of the numbers of veterans returning from Iraq and Afghanistan, because of the aging of the Vietnam era veterans, has faced a major increase in the demand for services.

And it simply hasn't had enough doctors and other caregivers to meet the demand. But we have to look beyond the obvious because these are the types of problems that American healthcare is facing broadly. There simply are not enough primary care providers in the country. There simply are not enough mental health care providers in the country. Part of what we need to do, though, in addressing these types of personnel shortages, is also to look how we can use technology to leverage these limited human resources. You know, Telehealth is one that's very obvious. If you can get a problem taken care of in the comfort of your home, that makes all the sense in the world.

RATH: One of the problems that you've written about is the growth of the centralized bureaucracy with the VA. Can you talk about how that's been a problem?

KAISER: VA is a national healthcare system. It has facilities in every state and, essentially, every major metropolitan area of the country. How you provide care in Anchorage, Alaska, or Los Angeles, or Miami or Manhattan is very different. So the organization needs to let the managers and the doctors who are in the field figure out how to do things within the context of having very clear direction about what the goals are and where the organization needs to move. And I think that the more that sort of frontline decision-making is concentrated in Washington, the more difficult it is to make the right decisions.

RATH: That's Doctor Kenneth Kaiser. He's a former Under Secretary for Health at the Department of Veterans Affairs and is now at UC Davis. Doctor Kaiser, thanks so much.